A newborn male infant, with an estimated gestational age of 35weeks, was born via spontaneous vaginal delivery to a 28year-old mother, who presented in active labour with a macular rash on her hands and feet noted at the time of delivery, as shown in Fig. 1(c–e). Maternal history was significant for illicit drug use and scant prenatal care, without thorough serological evaluation performed prior to delivery. Physical examination at birth revealed a small-for-gestational-age infant in moderate respiratory distress. He had a distended abdomen with hepatosplenomegaly. Dermatological examination demonstrated dry flaky skin throughout and some scattered petechiae. Laboratory evaluation was notable for haemoglobin of 13.3g dl1, leukocytosis of 81000 μl1 (55% segmented neutrophils, 19% monocytes, 21% lymphocytes, 1% bands and 2% eosinophils) and thrombocytopenia of 15000 μl1 . The C-reactive protein level was markedly elevated at 47.8mg l1. Liver function tests unearthed a transaminitis and significant hyperbilirubinaemia at time of birth, which subsequently peaked at 16.6 μmol l1 (direct 9.9, indirect 6.2). Radiographs of extremities revealed a ‘somewhat serrated appearance of proximal femoral and humeral metaphyses’. Brain imaging with head ultrasound was normal. Abdominal ultrasound confirmed enlargement of the liver. Treatment was started for a suspected congenital infection – confirmed based on the images of the placental tissue (Fig. 1a, b). He received two platelet transfusions, one red blood cell transfusion and was started on ursodiol for treatment of conjugated hyperbilirubinaemia, at a dose of 8 mg kg1 divided twice daily. He responded to treatment and was well when discharged home at 2 weeks of life.
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